Status epilepticus
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Status epilepticus is a life-threatening neurological condition defined as five or more
minutes of continuous seizure activity or repetitive seizures without regaining
consciousness between episodes.
Mortality rates of status epilepticus are approximately 20-30%. Status epilepticus should be managed as a medical emergency.
Established SE refers to clinical or electrographic seizures that persist for 30 minutes or longer without full neurological recovery in between.
Refractory SE is defined as the persistence of convulsions despite adequate doses of two intravenous agents.
With prolonged seizures there is onset of impaired cerebral autoregulation with resulting impairment of cerebral perfusion and risk of hypoxic brain injury.
Immediate measures to manage status epilepticus include positioning the patient to avoid injury (semi-prone position with the head down), supporting respiration including the provision of oxygen, attempt to gain IV access, maintaining blood pressure, and the correction of any hypoglycaemia.
Other measures to consider:
Management will vary depending on whether the patient is in the pre-hospital or hospital setting.
In-hospital
The patients ABC should be managed as abiv
The patient's individualised emergency management plan, if immediately available, should be followed
1st line:
2nd line:
If no response to two doses of 1st line therapy then one of the 2nd line agents below should be used:
3rd line:
If second line agents fail to resolve seizure then a 3rd line agent should be used
minutes of continuous seizure activity or repetitive seizures without regaining
consciousness between episodes.
Mortality rates of status epilepticus are approximately 20-30%. Status epilepticus should be managed as a medical emergency.
Definitions
Convulsive status epilepticus (SE) is a prolonged convulsive seizure for 5 minutes or longer, or recurrent seizures one after the other without recovery in betweenEstablished SE refers to clinical or electrographic seizures that persist for 30 minutes or longer without full neurological recovery in between.
Refractory SE is defined as the persistence of convulsions despite adequate doses of two intravenous agents.
Pathology
Seizures are the result of repetitive cerebral neuronal firing and are thought to result from imbalances in excitatory glutamate neurotransmitters and inhibitory GABA neurotransmitters.With prolonged seizures there is onset of impaired cerebral autoregulation with resulting impairment of cerebral perfusion and risk of hypoxic brain injury.
Management
The early initiation of anticonvulsants is key to successful treatment
Immediate measures to manage status epilepticus include positioning the patient to avoid injury (semi-prone position with the head down), supporting respiration including the provision of oxygen, attempt to gain IV access, maintaining blood pressure, and the correction of any hypoglycaemia.
Other measures to consider:
- Parenteral thiamine (Pabrinex) should be given if alcohol abuse is suspected
- Pyridoxine hydrochloride should be given if the status epilepticus is caused by pyridoxine deficiency
- If hypoglycaemia is present give 150-200ml of 10% glucose rapidly or equivalent dose of 20% glucose infusion.
Management will vary depending on whether the patient is in the pre-hospital or hospital setting.
Pre-hospital
With the above ABC measures implemented where possible (some measures may not be available depending on setting (e.g. IV access, glucose infusion) an appropriate benzodiazepine should be administered. Diazepam (rectal) or Midazolam (buccal or intranasal) are advised for use in the community with the doses as per the tables below:| Age | Diazepam rectal solution (2 mg/mL, 4 mg/mL) dose By rectum |
|---|---|
| NEONATE | 1.25–2.5 mg, repeated once after 5–10 minutes if necessary |
| CHILD 1 MONTH –1 YEAR | 5 mg, repeated once after 5–10 minutes if necessary |
| CHILD 2–11 YEARS | 5–10 mg, repeated once after 5–10 minutes if necessary |
| CHILD 12–17 YEARS | 10–20 mg, repeated once after 5–10 minutes if necessary |
| ADULT | 10–20 mg, repeated once after 5–10 minutes if necessary |
| ELDERLY | 10 mg, repeated once after 5–10 minutes if necessary |
| Age | Midazolam oromucosal solution dose By buccal administration |
|---|---|
| NEONATE | 300 micrograms/kg, repeated once after 5–10 minutes if necessary |
| CHILD 1–2 MONTHS | 300 micrograms/kg (max. 2.5 mg), repeated once after 5–10 minutes if necessary |
| CHILD 3 MONTHS–11 MONTHS | 2.5 mg, repeated once after 5–10 minutes if necessary |
| CHILD 1–4 YEARS | 5 mg, repeated once after 5–10 minutes if necessary |
| CHILD 5–9 YEARS | 7.5 mg, repeated once after 5–10 minutes if necessary |
| CHILD 10–17 YEARS | 10 mg, repeated once after 5–10 minutes if necessary |
| ADULT | 10 mg, repeated once after 5–10 minutes if necessary |
In-hospital
The patients ABC should be managed as abiv
The patient's individualised emergency management plan, if immediately available, should be followed
1st line:
- IV Lorazepam 0.1mg/kg to a max dose of 4mg (If IV access and resuscitation facilities are available)
- Repeat dose after 5-10 minutes if seizure continues
2nd line:
If no response to two doses of 1st line therapy then one of the 2nd line agents below should be used:
- levetiracetam
- phenytoin
- sodium valproate
3rd line:
If second line agents fail to resolve seizure then a 3rd line agent should be used
- phenobarbital
- or general anaesthesia